A cross-sectional study on burnout and its individual and environmental correlates among hepatological surgery nurses in Hunan Province, China

Background Burnout is a widespread occupational phenomenon among nurses with significant adverse outcomes for nurses, patients, and society. It is thus important and urgent to understand burnout and its risk factors to guide interventions. This study aimed to examine the level of burnout and explore its individual and environmental correlates. Methods This cross-sectional study was conducted in Hunan, China. A total of 623 hepatological surgery nurses completed an online survey (response rate: 72.78%). Burnout was measured using the standard Maslach Burnout Inventory (MBI). Information on individual factors and environmental factors was collected by self-designed questionnaires. Results The scores of emotional exhaustion, depersonalization, and personal achievement in nurse burnout were 30 (26–34), 11 (8–14), and 23 (20–26) respectively. The prevalence of high burnout ranged from 52.81% for emotional exhaustion to 90.37% for decreased personal achievement. The three dimensions of burnout shared common correlates such as self-rated physical health and working environment, while also having additional unique correlates such as overwork, satisfaction with income, and age. Conclusion Hepatological surgery nurses in Hunan Province are suffering from high levels of burnout, which requires public attention and urgent interventions. Improvement of the physical health and working environment of nurses may be the most beneficial intervention measures to tackle various dimensions of burnout, while other targeted measures are also needed for each specific dimension.


Introduction
healthcare costs to the "Quadruple Aim" which adds reducing burnout [24], indicating the importance and urgency to address burnout. Due to the physical, psychological, and social toll burnout takes on nurses, it is essential and urgent to understand the risk factors that lead to burnout to guide further targeted interventions. The past scholarship has invested much effort in exploring the antecedents to nurse burnout, which may be generally classified into individual factors and environmental factors. Some common individual factors have been identified to be associated with burnout, including age, gender, education, marital status, income, number of kids, working hours per week, physical health, etc. In general, being male [25,26], having higher education [25,27], having a higher income [25,28], being unmarried [29,30], having no kids [29,31], longer working hours per week [21,25,32], and poor physical health [25,32] are associated with a higher level of burnout. For environmental factors, substantial evidence has documented that poor and stressful work environment, such as poor staffing ratios, increased workloads, lack of professional autonomy, lack of leadership support, and lack of colleague communication and collaboration, is associated with nurse burnout [12,19,21,29,33,34].
Although the literature is replete with research on nurse burnout, most studies did not distinguish nurses from different departments or focused on nurses from certain departments such as emergency, oncology, pediatric, primary, anesthesia, and hemodialysis. To our knowledge, little is known about nurse burnout in the hepatological surgery department with predominantly liver cancer patients, especially in China which used to be labeled "the leader in liver diseases" [35]. Liver diseases are one of the leading causes of morbidity and mortality in China [36]. It is estimated that over 20% of the Chinese population is affected by liver diseases, including hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, liver cirrhosis, liver cancer, non-alcoholic fatty liver disease (NAFLD), and alcohol-related liver disease (ALD) [35]. Based on recent epidemiological data, HBV, a leading cause of liver cancer, affects 90 million (6.52%) people in China, as compared to 2.2 million (0.71%) in the US [35]. According to a 2018 report by the International Agency for Research on Cancer, China has the 9th highest rate of liver cancer and the largest number of liver cancer in the world [37]. The high prevalence and huge disease burden of liver diseases in China pose significant challenges to the healthcare workers in the hepatological surgery department, especially nurses who are on the frontline to deal with patients directly [38]. It is thus crucial to understand the level of nurse burnout in the hepatological surgery department and identify risk factors to guide future intervention and improvement plans. The current study was conducted to examine the level of burnout that includes three dimensions (EE, DP, and PA), as well as explore two types of risk factors (individual and environmental), among a provincial sample of hepatological surgery department nurses.

Participants and procedure
This cross-sectional study was carried out in all 79 tertiary hospitals that have set up independent hepatological surgery departments in Hunan Province, China between June 2021 to July 2021. Since this was a provincial-level epidemiological study, we aimed to include as many nurses as possible to get an unbiased representative sample that included all eligible nurses for this study and to get a comprehensive understanding of the current level of nurse burnout. To realize this goal, we retrieved the name list of all registered nurses in all hepatological surgery departments in Hunan Province through the Hepatobiliary Health Education Chair of Hunan Province and approached each nurse for the study enrollment. The minimal sample size was calculated according to the form for cross-sectional study: n = z 2 P(1 − P) / E 2 , where P (the prevalence of burnout) was estimated at a minimum of 40% based on past studies, Z was set as 1.96 at a confidence interval of 95%, an allowable error was set as 5%. Considering a rejection or lost-to-follow-up rate of 20%, we got a final minimal sample size of 443. The inclusion criteria of the subjects were as follows: (a) full-time registered nurses with effective professional qualification certificates; (b) specialized hepatological nurses; (c) aged � 18. The exclusion criteria were as follows: (a) nurses who rotated, visited, and/or studied in the hepatological surgery department; (b) nurses who were on leave due to sickness, maternity, or other reasons during the survey; (c) nurses who were unable to fill in the online questionnaire due to physical or mental illness. A list of all eligible nurses was achieved from each hepatological surgery department in each hospital after the official permission was granted. The eligible nurses were invited to participate in an online survey through Sojum [39]-a most popular professional online survey tool in China that provides multiple services including questionnaire design and distribution, data collection, and analysis. All nurses were fully informed of the study's purpose and procedure. Since the study was conducted online instead of face-to-face, all participants provided their written informed consent electronically through Sojum before filling in the online questionnaire. In order to protect participant privacy, each questionnaire was de-identified and authors had no access to any information that could identify individual participants during or after data collection.
In total, 856 nurses from the hepatological surgery departments of the 47 hospitals were eligible for the study and invited to participate in the online survey. After excluding 146 nurses who refused to respond, 38 nurses with obvious logical mistakes in their answers, and 49 nurses with a too-short response time in filling in the questionnaire (3 SD below the average response time), our final effective sample was 623 (response rate:72.78%), which satisfies the minimal sample size requirement of 443. Each item of the online questionnaire was required to be filled in before submission and as a result, there is no missing data in the final dataset. Ethics approval was obtained from the Institutional review board (IRB) of the Hunan Provincial People's Hospital (No.: Ky-2021-65).

Measures
The questionnaire for this study included the following three parts: (a) individual factors that include both socio-demographic information and work-related characteristics; (b) environmental factors that include hospital-level, department-level, colleague-level, and patient-level factors; and (c) the outcome variable of burnout that includes the following three dimensions: EE, DP, and PA.
Environmental factors. The working environment was evaluated with a self-designed 4-item working environment scale that was specifically designed for this study. The scale asked about the importance and respect participants received from the following four sources of work: the hospital, the department, colleagues, and patients. For the hospital and department level, the participants were asked if the hospital/department attached enough importance to the development of nursing in the hepatological surgery department. For the colleague level, participants were asked if they had harmonious relationships with their colleagues. For the patient level, participants were asked if they were respected by their patients. Each item was rated on a five-point Likert scale ranging from '1' (extremely no) to '5' (extremely yes). The total score of the working environment scale ranges from 4 to 20, with a higher score indicating a better working environment for the nurses. In this study, the mean value of 16 was used as a cutoff to distinguish those with a poor and good working environment. The working environment scale showed acceptable internal consistency with a Cronbach's alpha coefficient of 0.78.
Burnout. Burnout was measured by the Maslach Burnout Inventory (MBI), which is the most widely used standard scale for workplace burnout all over the world [40]. The MBI includes 22 items under three dimensions: emotional exhaustion (EE) characterized by extreme tiredness due to excess efforts (9 items), depersonalization (DP) characterized by negative attitudes in interpersonal relationships (5 items), and personal accomplishment (PA) characterized by negative self-assessment (8 items) [40]. Each item is rated on a seven-point Likert scale ranging from '0' (never) to '6' (every day). Sample items include "I feel emotionally drained from my work," "I don't really care what happens to some recipients," and "I deal very effectively with the problems of my recipients." The total score of each subscale ranges from 0-54 for the EE, 0-30 for the DP, and 0-48 for the PA, with scores of �27 on EE, �10 on DP, or �33 on PA representing high burnout for the associated dimension [40]. In addition, to get a combined score for the MBI, we reverse-coded each item of the PA to get a transformed subscale-decreased personal accomplishment (DPA) [26]. The total score of MBI was calculated by summing up the scores of EE, DP, and DPA and ranges from 0-132, with higher scores indicating higher levels of burnout. The Chinese version of MBI was first validated by You et al. and has been widely used in the Chinese population [41]. In the current study, the MBI showed good internal consistency with a Cronbach's alpha coefficient of 0.91. Data analysis. All data were analyzed using STATA1 version 13. Sample characteristics were examined using descriptive statistics, with continuous variables represented by means ± standard deviation, and categorical variables by numbers and percentages in each category. Comparisons of burnout scores including EE, DP, and DPA by individual and environmental characteristics were conducted by t-test or ANOVA test as appropriate. Correlates of burnout and its three dimensions were explored by multivariate linear stepwise regression analysis with backward selection. Table 1 provides a detailed summary of the sample characteristics that include individual factors (socio-demographic and work-related factors), environment factors (hospital, department, colleague, and patient-level), as well as the primary outcome burnout score (EE, DP, DPA). For socio-demographic characteristics, the nurse profile was consistent with a 30-yearold married female with a college education and with kids. Regarding work-related characteristics, most nurses were in their junior nursing career with primary titles and were generally unsatisfied with their income. They also had long working hours, night shifts, additional work assignments, and overtime work. As for the working environment, only half reported a good working environment. For job burnout, the nurses reported an alarmingly high level of burnout, with the prevalence of high EE, DP, and PA being 52.81%, 83.79%, and 90.37%, respectively. Table 2 presents a comparison of various burnout scores (MBI, EE, DP, DPA) by individual and environmental factors. For both the total MBI scale and its three subscales, nurses who were satisfied with income, in good self-rated health, and good working environment showed significantly lower burnout scores than their counterparts. Nurses who worked �40 hours per week, worked overtime, and had additional work assignments reported significantly higher burnout scores than their counterparts. In addition, females reported higher burnout scores than males, reflected in the total MBI scale and the EE subscale. Contract nurses and nurses with nightshifts reported higher burnout scores than their counterparts, reflected in the EE subscale only.

Burnout scores by individual and environmental factors
Correlates of burnout. Table 3 shows the results of multiple stepwise linear regression analyses with MBI and subscales scores (EE, DP, DPA) as the dependent variables, while individual and environmental factors as independent variables. For the total MBI scale, four factors remained significant in backward regression: self-rated physical health (β = -6.68, p<0.001), working environment (β = -6.51, p<0.001), overwork (β = 4.13, p = 0.008), and satisfaction with income (β = -3.31, p = 0.007). For the cross-comparisons of the correlates of the three

Summary of findings
To our knowledge, this is the first study to comprehensively examine the level of burnout (including the total MBI scale and its three subscales) and explore its individual and environmental correlates among a provincial-level sample of nurses from the hepatological surgery department. Our results showed a generally high level of burnout among hepatological surgery nurses with a high score in the total MBI scale and its three subscales. The prevalence of high burnout varied across the three subscales, indicating different levels of burnout by dimensions. Better self-rated health, a better working environment, no overwork, and satisfaction with income were associated with a lower risk of general burnout. For the three dimensions of burnout, self-rated physical health and the working environment remained consistently significant correlates across EE, DP, and DPA, while each subscale also has its additional unique correlates.

Levels of burnout
Our study showed a significantly high level of burnout in each dimension among hepatological surgery nurses in Hunan Province. These scores were worse than the reported 23.95 ± 11.11 for EE, 7.90 ± 6.5 for DP and 27.51 ± 10.96 for PA in Wang et al [42]'s study among general nurses in Tianjin Province of China. But these scores were generally comparable to the reported 30 (26)(27)(28)(29)(30)(31)(32)(33)(34) for EE, 11 (8)(9)(10)(11)(12)(13)(14) for DP, and 23 (20)(21)(22)(23)(24)(25)(26) for PA in Meng et al [25]'s study among nurse anesthetists in Shandong Province. The prevalence of high burnout for EE (52.81%), DP (83.79%), and DPA (90.37%) was much higher than the reported 11.34% for EE, 7.4% for DP, and 64.02% for DPA in Guo et al [29]'s recent study among Hemodialysis nurses in 31 provinces in mainland China. The prevalence of high burnout in our study was also much higher than the reported 28% in the US [43], and the reported 11.23% by a recent systematic review and meta-analysis among global nurses across multiple specialties in 49 countries [9]. In general, our results showed an alarmingly higher level of burnout among hepatological surgery nurses in Hunan Province than most of the other studies conducted in other areas of China or other countries. Several reasons may explain the high burnout rate in our study. First, most patients cannot eat after hepatological surgery and rely on nasogastric tubes for nutrition intake, which may increase both the workload and difficulty level of nursing. Second, patients with hepatological surgery are at high risk of post-surgery adverse events such as drain falling off, and it requires expertise, experience, time, and patience for nurses to care for such patients. Third, most patients in hepatological surgery department were under serious condition such as liver cancer, the poor prognosis and low survival may add additional emotional burden to the nurses who are in direct contact with the patients. Furthermore, under the global pandemic of COVID-19, the strict safety requirement in the hospital adds extra burden to the nurses who are already overwhelmed by their intensive routine nursing work [44]. Additionally, as frontline health care providers, nurses are at high risk of getting infected with Covid-19 and infecting others, which further aggravate their psychological distress [44]. All these factors may contribute to the high burnout in nurses of hepatological surgery department in our study. This calls for high importance to be attached to the phenomenon of burnout and active measures to be taken to alleviate burnout among hepatological surgery nurses in Hunan Province. Among the three dimensions of burnout, the DPA dimension showed the highest burnout prevalence, with over 90% of nurses reporting decreased personal achievement, a pattern consistent with most of the other studies in China [29]. Apart from systematic reasons such as the prevalent nursing staff shortage and high workloads among nurses all over the country, several specific work-related characteristics of the sample may also explain the nurses' low level of personal achievement in the study. For instance, the majority of nurses were in contract employment, with the lowest professional and job titles, which all indicate low career development prospects and as a result low personal achievement from work. These findings have implications for future intervention programs to focus on improving nurses' career development to improve their achievement and finally to reduce burnout. This may be realized through multiple career training programs to strengthen their competency as well as the expansion of various promotion opportunities to advance their professional development.

Correlates of burnout
The study showed that self-rated physical health and working environment were the only two common correlates across all three dimensions of burnout: EE, DP, and PA. Compared to nurses with poor physical health, nurses with good physical health were at lower risk of burnout, reflected in lower levels of emotional exhaustion and depersonalization, and a higher level of personal achievement. This finding was consistent with previous findings showing poor physical health as a risk factor for burnout [25,32]. Nurses act as professional multi-tasking caregivers at hospitals and undertake many important duties to care for patients and support other health providers. Apart from direct patient work such as medication administration, post-surgery care, medical information and records updates, and routine monitoring of patients, nurses also shoulder the task of communication among patients, families, and other health providers to coordinate and implement treatment and care plans. The multiple highintensity nursing duties, combined with irregular working hours and night shifts all require nurses to have good physical health to maintain their work. Nurses with better physical health are more competent to satisfy the diverse and high-demanding working requirements, and as such, are less likely to suffer from the emotional overextension and depletion resulting from work stress, to show negative attitudes towards patients, and to feel incompetent or dissatisfied with their work.
On the other hand, the negative association between physical health and burnout may reflect a bidirectional relationship between them, that is, not only does poor physical health leads to high burnout, but also high burnout leads to poor physical health. As previous evidence has robustly demonstrated the negative impact of burnout on physical health, including fatigue, headache, insomnia, appetite changes, chest pain, frequent colds, gastrointestinal distress, heart disease, and even mortality [13,14]. Our findings underline the importance of maintaining nurses' physical health in combatting their job burnout, which may be realized through promoting healthy lifestyles such as healthy eating and regular exercise among nurses through education and propaganda. Our study also suggests for future longitudinal studies to explore the potential bidirectional relationship between physical health and burnout.
Consistent with the bulk of literature highlighting the essential role the working environment played in nurse burnout [12,19,21,29,33,34], our study also showed that a good working environment was strongly associated with a lower risk of burnout. To be specific, nurses with high levels of hospital and department support, harmonious colleague working relationship, and received high respect from patients had lower levels of emotional exhaustion and depersonalization, and a higher level of personal achievement. Substantial previous evidence has documented that the lack of support from leadership, lack of collaboration among colleagues, and lack of patient trust and respect were leading factors that contribute to nursing burnout [21,29]. Our findings add further support to the previous studies and suggest improvements in the working environment to reduce nurse burnout, which has already been may significantly decrease nurse burnout, which may significantly minimize the negative impacts of nurse burnout on patient outcomes as well as improve patient satisfaction [19,34,45,46].
Apart from the two common correlates across all three dimensions of burnout, our study also showed each dimension has its unique additional correlates. For instance, EE was associated with overwork and satisfaction with income, DP was associated with satisfaction with income, and DPA was associated with age. The positive associations between satisfaction with income and low levels of EE and DP were in alignment with previous studies showing higher income as a protective factor for job burnout [25,28]. This finding suggests raise in income may be beneficial in improving nurses' burnout in terms of EE and DP. Having to work overtime indicates a higher level of job stress, which has been consistently shown to be contributing factor leading to emotional distress [42]. This finding suggests that reducing workload and avoiding overwork can help decrease nurses' emotional exhaustion. The higher level of burnout in terms of personal achievement among older nurses may reflect a lower professional development room with aging and suggest the need of providing more advanced education and training opportunities for older nurses to improve their achievement. In summary, these findings underscore the different correlates of various dimensions of burnout, which may require different targeted interventions.

Limitations
This study has several limitations that should be considered when interpreting the results. First, the sample was limited to hepatological surgery nurses in Hunan Province; the results, therefore, may not extend to nurses in other specialties, or in other areas of China. Future studies may consider using nationally representative samples of nurses in various specialties to get a more comprehensive picture and facilitate better comparisons. Second, the cross-sectional study design makes it impossible to establish causal relationships between risk factors and burnout. Future longitudinal or interventional studies are highly recommended to robustly demonstrate causal relationships. Third, the evaluation of the working environment was based on a self-designed 4-item scale, which may not represent the psychosocial work environment fully. Future studies should consider including a broad assessment of psychosocial environment factors such as risky work tasks, work demands, work content (task clarity, unexpected responsibilities), decision latitude, decision-making authority.

Conclusions
In this study on burnout among hepatological surgery nurses in Hunan Province, we found alarmingly high levels of burnout in terms of emotional exhaustion, depersonalization, and decreased personal achievement, which deserves public attention and calls for urgent interventions to relieve nurse burnout. Self-rated physical health and the working environment remained two common correlates across all three dimensions of burnout, highlighting the improvement of physical health and the working environment of nurses may be the most beneficial intervention measures to tackle various dimensions of burnout. Apart from the common correlates, each dimension of burnout has its unique additional correlates such as overwork, satisfaction with income, and age, implying the need for targeted interventions for each specific dimension of burnout.